O’Connor K. Ending the opioid crisis in five years. Harvard Public Health Review. 2021; 30.
Ending the Opioid Crisis in Five Years
In 2017, 70,237 people died from drug overdose; my little sister Jenny was just one of them. I watched her die from prescription opioids over the course of six days at Kenmore Mercy hospital near Buffalo, NY. Jenny was a 44-year-old suburban mom and college graduate. She died with my parents on either side of her bed holding her hands. My mom was wearing a baseball hat. I never saw her cry. My dad, a Vietnam combat Veteran and Bronze Star recipient, was silent. My sister Colleen and I sat at the foot of the bed, with a perfectly framed picture of our youngest sister and my parents, one that I’ll never be able to forget. It was a heartbreaking and gruesome death for my sister and our family.
According to the Centers for Disease Control and Prevention, from 1999 to 2017 more than 702,000 Americans died from a drug overdose; 477,000 (68%) of those deaths involved a prescription or illegal opioid. In 2017, 46 percent of American adults had a family member or close friend who struggled with addiction. Millennials are dying at such high rates it has driven life expectancy in the U.S. to decline for two years in a row, for the first time since the early 1960s. The emergence of the synthetic opioid fentanyl, 50 times more potent than heroin, is partially to blame. An estimated one in five deaths among U.S. adults ages 25 to 34 are related to opioid use according to the Journal of the American Medicine Association. This public health crisis continues to metastasize across America with no end in sight.
Between 2006 and 2012, more than 76 billion opioid pills were dumped across the country according to a database maintained by the U.S. Drug Enforcement Agency, enough pills to create an entire nation of addicts.
Ending the opioid crisis requires citizens to get educated and use our collective power as consumers, voters, and patient advocates for our loved ones to push the private sector and government for patient-centered solutions.
20 Years of Legally Flooding the U.S. Market with Prescription Opioids
In the mid-1990s, doctors were treating pain more aggressively because the American Pain Society was defining pain as the fifth vital sign to raise awareness that patients with pain were undertreated. At the same time Purdue Pharma was aggressively marketing OxyContin directly to doctors as a non-addictive pain medication. A 2018 New York Times report alleged that Purdue was well aware of the potential risks of opioid addiction as early as 1996 when they received reports that early users were engaging in abuse of their drug, but Purdue continued their aggressive marketing.
In Sam Quinones’s book Dreamland he describes how the confluence of these two things created massive waves of addiction in rustbelt communities, where patients who suffered from chronic pain became addicted to opioids while simply following their doctors’ orders.
But Purdue Pharma didn’t act alone. In Dopesick: Dealers, Doctors, and the Drug Company that Addicted America, Beth Macy claims that in addition to the actions of Purdue Pharma, lobbyists, drug distributors, lawmakers, lobbyists, and “pill mills” that dispensed large quantities of prescription drugs for cash were also responsible for creating the opioid crisis. Quinones describes pill mills as places “where a doctor prescribes pills for cash without almost any diagnosis of any pain problems or anything like that. Pill mills usually have long, long lines, and they prescribed millions of pills a year and are one of the main reasons why so many people got addicted.”
Pill mills thrived between 2006 and 2012 when a deluge of 76 billion addictive pain pills were dumped across America, tracing a majority of the manufacture and distribution of those pills to just nine companies: three companies (Mallinckrodt, Actavis Pharma, Endo Pharmaceuticals) manufactured 88 percent of those pills, and the six companies (McKesson Corp., Walgreens, Cardinal Health, AmerisourceBergen, CVS, Walmart) distributed 75 percent of those pills.
Pill mills were rampant in small towns like Kermit, West Virginia, (population 392), where one pharmacy received 5.7 million hydrocodone and oxycodone pills between 2005 and 2011 from McKesson, which shipped over 100 million pills into the state during that time. Mallinckrodt flooded Florida (population 20 million) with 500 million oxycodone pills between 2008 and 2012. One Florida doctor, Barry Schultz, prescribed a patient 23,000 pills over eight months — that’s 100 pills a day.
Shockingly, government regulators and law enforcement knew exactly where every pill went, year by year, town by town, but fought to keep that data hidden from the public, suppressing corporate information even when it could have benefited the public’s health and safety.
Big pharma wasn’t the only industry that played an intentional role in creating the opioid crisis. In legal papers released as part of the more than 2,000 opioid legal cases now underway, the Massachusetts attorney general alleged that McKinsey, a top tier consulting firm, advised Purdue Pharma on how to “turbocharge” sales of OxyContin and counter efforts by drug enforcement agents to reduce opioid use and was part of a team that looked at how “to counter the emotional messages from mothers with teenagers that overdosed” on the drug.
The opioid crisis is a 20-year assault on patients with a perfect storm of gross negligence of government regulators, law enforcement hiding information and data that could have helped the public, and corporate predatory behavior in pursuit of profits at the expense of patient health.
Opioid Crisis Profit and Loss (P&L): Private Sector Profits at the Expense of Government
Internal Purdue records indicate OxyContin had more than 28% of the total market share in gross sales of opioids each year from 2008 through 2018. Since 1996, sales of OxyContin have totaled more than $35 billion, with the Sackler family, who ran Purdue, receiving $12-13 billion in company profits. Mallinckrodt generated $18 billion from sales of opioids from 1996 to 2017, according to court records that were unsealed in 2019 federal court in Ohio—where more than 2,000 lawsuits have been consolidated.
Annual opioid sales nationwide rose from $6.1 billion in 2006 to $8.5 billion in 2012, according to industry data gathered by IQVIA, a health care information and consulting company. Individual drug company revenues ranged in single years at the epidemic’s peak from $403 million for opioids sold by Endo to $3.1 billion in OxyContin sales by Purdue Pharma, according to a 2018 lawsuit against multiple defendants by San Juan County in New Mexico.
The White House Council of Economic Advisors estimated the opioid crisis was $504.0 billion, or 2.8 percent of GDP in 2015 alone. A report from the National Center for Biotechnology Information (NCBI) found that between 2000 and 2016, opioid misuse cost state governments $11.8 billion, including $1.7 billion in lost sales tax revenue and $10.1 billion in lost income tax revenue. In addition, the federal government lost $26.0 billion in income tax revenue.
In 2019, a federal case in Cleveland includes more than 2,000 lawsuits, largely from various levels of government, in an effort to reach a single landmark legal resolution to the opioid epidemic making drug makers and distributors help pay for solutions. There are two major legal arguments behind these cases, one against opioid manufacturers for fraudulent advertising and another against opioid distributors for insufficient monitoring of suppliers. Other cases are proceeding as well in Connecticut and Massachusetts, and Oklahoma.
The judge in Oklahoma ruled in August against Johnson & Johnson (J&J) in the state’s opioid suit, forcing the company to pay $572 million in the first ruling in the U.S. holding a drugmaker accountable for helping fuel the epidemic. The $572 million judgment against J&J covers just one year of costs under the state’s plan to combat the crisis, even though the attorney general’s office presented several witnesses who said it would take at least 20 years to carry out. J&J is appealing the ruling.
Call to Action
The opioid crisis is a partially manufactured problem, but it’s also a fixable one. Citizens need to get educated about prevention and treatment and pressure elected officials to prioritize this issue in their campaigns and work. The public and private sectors need to do more to fix a problem they helped create, and our elected officials need to lead.
Citizens: Get Educated and Engaged
The main reason I tell our family’s story is so that other families don’t make the same mistakes I did. Our family isn’t unique. It isn’t the saddest story. But it’s a chilling example of how shame, stigma, and ignorance render families helpless in this health crisis.
My sister Jenny was just one of the 90 percent of 20.7 million Americans with substance use disorder who never get the specialty treatment they need. I was blindsided by what happened with my sister. I experienced her addiction, suffering, and death in just six days in July 2017. She didn’t do a single stint in rehab or have any interventions. She started taking pain medication following a surgery, and in a few years was taking an uncoordinated cocktail of medications from different doctors. She died without our family ever having an honest conversation about her illness. She never had a chance, because she was too ashamed to ask for help. I am not ashamed of my sister, but I’m so ashamed of myself for not being educated about substance use disorder sooner.
Getting effective help with substance use disorder is often a major struggle, because until recently, medical schools offered little training in addiction medicine. My sister might have lived if she had received drug screening, medication-assisted treatment and behavioral counseling that was integrated into her primary health care — the “National Principles of Care” that medical experts now evangelize. She might have lived if she had a doctor who was board-certified in addiction medicine and received medication assisted treatment (MAT), in which FDA-approved drugs that reduce withdrawal and drug cravings are prescribed in tandem with counseling.
A Systems Thinking Approach to Ending the Opioid Crisis in Five Years
The public and private sectors need to collaborate more effectively on patient-centered solutions, and our elected officials in both parties need to lead.
Fixing this crisis is not only the right thing to do but also good business for the private sector. Executives at 181 of America’s biggest companies have redefined the purpose of a corporation to include “improving our society by operating ethically.” Now that the truth is finally being made public with evidence from more than 2,000 opioid lawsuits, individuals and corporations that broke the law should get the justice they deserve and be made to pay to fix a problem they helped create.
Congress and the president need to ensure effective legislation and adequate funding for states is in place. The CARE Act is a comprehensive plan to fix the opioid crisis over the next decade and provides states with funds needed to prevent and treat substance use disorder: $100 billion would be invested to build an addiction treatment infrastructure modeled on the approach to address the HIV epidemic. The plan addresses treatment, training for health professionals, monitoring and surveillance, prevention, and expanded access to naloxone.
Government agency secretaries and senior executive service (SES) leaders need to improve their agencies’ performance and patient-centered outcomes, taking a more data-driven, scalable approach and leverage things that are already working. For example, Vermont uses a “hub and spoke” model to create a comprehensive treatment plan for addiction recovery. In my hometown of Buffalo, the first opioid treatment court was launched in 2017 to expedite treatment for defendants.
The scale and complexity of this crisis requires a systems thinking approach. We need ubiquitous access to medication assisted treatment (MAT); education to eliminate shame associated with addiction, an overhaul of treatment in the criminal justice system, more drug treatment courts, more doctors who are certified in addiction medicine and licensed to prescribe MAT medications, expanded access to naloxone, improved monitoring and surveillance technologies, more innovative law enforcement tactics to combat illegal opioids, and research to develop non-addictive pain medication.